Exhibit – FEDMER Social Security Disability Eligibility Statement 

Federal Medical Evidence of Record (FEDMER) 

Social Security Disability Eligibility Statement 

Keep a copy of this form 

Name_____________________________SSN__________________________________ 

Please put a check mark in the box next to the number that describes your situation, and follow the instructions for that section. 

 you have not checked Box 1 or 2, above, please check Box 3 and follow the instructions. 

 1. I am already receiving Social Security disability benefits. I will provide my Human Resource office with 

proof (e.g. copy of my Social Security Award Certificate). 

 2. I have filed for Social Security disability benefits, but I have not received a decision. I will provide my 

Human Resource office with proof (e.g., copy of Social Security disability application receipt, copy of the 

ISBA page “What You Need to Do Now”, etc.).). 

 

If you checked either #1 or #2 above, sign and date the statement below, and return it to your Human 

Resource office with the documentation indicated. Do not check any further blocks, or take any other 

action. 

My signature below verifies my status. 

Signature: ___________________________________________ Date: _________________ 

If

Und

 3. I have not filed for Social Security disability benefits, OR I have filed and have been denied. Since I am 

now filing for FERS disability, I understand I also need to file for Social Security disability benefits. 

 you checked block #3, you need to apply for Social Security disability using either the: 

• Application for Social Security 

benefits" at http://www.socialsecurity.gov/applyfordisability/adult.htm

If

Internet to complete the “Online Adult Disability Report” and the "Online 

 OR

•

ur 

 can use to prepare for your interview. You can also see the starter kit 

at the Internet site shown above. 

to 

 of this 

rm and a copy of any medical records you have obtained for your FERS disability claim. 

r 

 receipt, which is needed by them in order to complete 

e processing of your FERS disability application. 

Contact Option: Contact Social Security to schedule an appointment to file your Social Security disability 

claim. You can call Social Security’s national toll-free telephone number (1-800-772-1213) or contact yo

local Social Security office. When you make your appointment, Social Security will provide you with an 

“Adult Disability Starter Kit” that you

Whether you use the Internet or the Contact Option to file, a Social Security representative will contact you 

complete your disability application. At that time you will need to provide to Social Security a copy

fo

When you file your disability application, Social Security will provide you with a receipt. You must provide you

Human Resource office with a copy of the application

th

er FEDMER (the Federal Medical Evidence of Record program), Social Security will: 

1) Use the medical records you provide to expedite the processing of your Social Security disability claim. (If additional 

medical evidence is needed to process your disability application, the State Agency making the decision will let you 

know.) 

2) Share a copy of the medical decision with the Office of Personnel Management (OPM). When your Social Security 

disability claim is processed, Social Security will send a copy of any award or denial notice to the U.S. Office of Personnel 

Management (OPM), Claims 1 Group, Room 4458, 1900 E St. NW, Washington D.C. 20415, Attn: FEDMER.